Shoulder instability

What is shoulder instability?

The shoulder is a ball sitting on a shallow socket. This lets the arm move in almost any direction, but it also means the ball can slip out. A full slip is a dislocation. A partial slip is called a subluxation.

Most dislocations happen toward the front of the shoulder, often during a fall or contact sport. The force can tear the labrum, the ring of tissue that deepens the socket. This is called a Bankart tear. It may also chip the bone of the socket or dent the ball.

Instability means the shoulder keeps feeling loose or keeps slipping out. Some people feel nervous with the arm raised and turned back, as in throwing.

What should I do after a first dislocation?

If your shoulder is still out, go to an emergency department. Do not try to force it back in. Once it is back in place, you will usually have X-rays and a sling for a short time, then see a shoulder specialist. An MRI is often used to look for a tear.

Your next step depends on your risk of it happening again. In an international consensus, 65 shoulder surgeons agreed on what to weigh. The list includes your age, gender, how the injury happened, how many times the shoulder has come out, and whether someone had to put it back in. It also includes your job, your sport and level of play, whether you play a collision sport, any bone loss, and how loose your joints are in general (Hurley, 2022).

Do I need surgery after a first dislocation?

Not always. Many people choose a sling and physical therapy first, and that is a reasonable path. The choice depends on what you want to do with your shoulder.

A review of five randomized trials compared early surgery with a sling alone. The patients were young, with an average age of about 23. Over about five years, 46.6% of people treated with a sling had the shoulder become unstable again, compared with 6.3% after surgery. In all, 30.8% of the sling group later had stabilizing surgery, compared with 4.0% of the surgery group (Belk, 2023).

There are two ways to read those numbers. Surgery lowered the chance of it happening again for young, active people. But more than half of the people in the sling group did not have another episode, and about two out of three had not needed surgery by the end of the studies. Those trials also do not describe everyone. Older adults and people with less demanding sports or jobs may see things differently.

If you are a young athlete in a contact sport, early surgery is more likely to come up. If this was a one-time event and you are not chasing a high-risk sport, therapy first may suit you well.

What is a labral repair?

A labral repair, or Bankart repair, is most often done by arthroscopy. Working through small incisions with a camera, the surgeon reattaches the torn labrum to the rim of the socket with small anchors and stitches. This restores the bumper at the front of the socket and tightens the loose tissue.

In the same consensus, surgeons agreed that complications after Bankart repair are rare. They also agreed that a clear rehabilitation plan and careful selection of patients help lower the chance of the shoulder slipping out again (Hurley, 2022).

Labral repair works less well when bone has been lost from the socket or the ball, or when a shoulder has come out many times. In those cases, a different operation may be a better fit.

What is a Latarjet?

A Latarjet is a stabilizing surgery that uses bone. The surgeon moves a small piece of bone from the front of the shoulder blade, along with the tendons attached to it, to the front of the socket. It is held in place with screws. This makes the socket wider and adds support at the front.

A Latarjet is more often discussed when the socket has lost bone, when a prior repair has failed, or when the risk of the shoulder slipping out is high.

A review of seven cohort studies compared arthroscopic Bankart repair with the Latarjet. The shoulder was more likely to become unstable again after Bankart repair, and that gap showed up most at 6 to 10 years. Shoulder scores and the need for revision surgery were similar. Infection was less common after Bankart repair (Imam, 2021). These studies were not randomized, so the shoulders in each group may have differed from the start.

A Latarjet is a larger operation. A review of 2,560 Latarjet procedures reported an overall complication rate of 16.1%, which included nerve injuries in 1.9%. About 2.6% of patients needed an unplanned second operation. Serious complications appeared rare in the short term (Cho, 2023).

Neither surgery is right for everyone. Dr. Pareek will review your bone loss on imaging, your sport, and your goals with you. Results vary.

Should I get a second opinion?

It can help if your shoulder keeps slipping after a past repair, or if you are unsure which surgery fits you. Here’s how a second opinion works.

Where can I see Dr. Pareek?

Dr. Pareek sees shoulder patients at HSS in New York and at HSS in New Jersey. Bring any X-rays, MRI or CT images, and reports you already have.

What does recovery look like?

These are typical ranges. Your surgeon’s plan comes first, and recovery varies from person to person.

• Weeks 0-4: Protect the repairYou usually wear a sling most of the time, with limits on how far the arm can move. You can often use the hand and elbow for light tasks.
• Weeks 4-6: Restore motionPhysical therapy begins to bring back shoulder motion in careful steps. Reaching and lifting are still limited.
• Weeks 6-12: Start strengthGentle strength work begins for the shoulder and shoulder blade muscles. Motion keeps improving over about three months.
• Months 3-4: Build controlExercises grow harder and more specific to your sport or job. Heavy lifting builds up slowly.
• Months 4-6: Return to sportMany people return to sport or demanding work in this window. Contact athletes may need longer, and a Latarjet also depends on the bone healing. These are typical ranges, and your surgeon's plan governs.

Sources

1. Belk JW, et al. Shoulder stabilization versus immobilization for first-time anterior shoulder dislocation: a systematic review and meta-analysis of level 1 randomized controlled trials. Am J Sports Med 2023;51:1634-1643.
2. Hurley ET, et al. Anterior shoulder instability part I: diagnosis, nonoperative management, and Bankart repair: an international consensus statement. Arthroscopy 2022;38:214-223.e7.
3. Imam MA, et al. Bankart repair versus Latarjet procedure for recurrent anterior shoulder instability: a systematic review and meta-analysis of 3275 shoulders. Am J Sports Med 2021;49:1945-1953.
4. Cho CH, et al. Complications related to Latarjet shoulder stabilization: a systematic review. Am J Sports Med 2023;51:263-270.